What are the guidelines for performing a pericardial window?

Guidelines for Performing a Pericardial Window

A pericardial window is primarily indicated for recurrent large pericardial effusions or cardiac tamponade, especially in patients with malignant disease or when pericardiectomy poses high risk due to patient condition or limited life expectancy. 1

Indications

• Recurrent large pericardial effusions
• Cardiac tamponade requiring palliative intervention
• Malignant pericardial effusion with high likelihood of recurrence
• Patients with limited life expectancy where pericardiectomy would be too invasive
• Purulent pericarditis
• Traumatic hemopericardium
• Failed pericardiocentesis
• Loculated effusions not amenable to needle drainage 1, 2

Surgical Approaches

1. Conventional Surgical Approach

• Performed by cardiac surgeons
• Creates a communication from pericardial space to pleural cavity
• Typically performed via:
  • Subxiphoid approach (preferred for diagnostic purposes in stable patients) 3
  • Left anterior thoracotomy
  • Median sternotomy (when more extensive access is needed) 1

2. Video-Assisted Thoracoscopic Surgery (VATS)

• Less invasive alternative to open surgical approach
• Can be performed through:
  • Standard multi-port technique
  • Single-port technique (in select cases) 4, 5
• Benefits include:
  • Reduced surgical trauma
  • Shorter hospital stay
  • Earlier recovery 5

3. Percutaneous Balloon Pericardiotomy

• Creates a pleuropericardial communication
• Effective (90-97%) for large malignant effusions and recurrent tamponade
• Should be avoided in neoplastic or purulent effusions 1

Procedural Considerations

Anesthesia

• Typically performed under general anesthesia
• In select high-risk patients, can be performed under local anesthesia with sedation 4

Technique

• A 3-4 cm section of pericardium is excised
• Pericardial fluid should be sent for:
  • Cytology (especially in suspected malignant effusions)
  • Bacterial cultures
  • Histological/immunohistological evaluation
  • PCR for microbial agents when indicated 1

Drainage Management

• Extended pericardial drainage is recommended in malignant effusions
• Continue drainage until output is <25 ml per day 2

Special Considerations for Malignant Effusions

Intrapericardial Therapy

• Intrapericardial instillation of cytostatic/sclerosing agents should be considered
• Agent selection should be tailored to tumor type:
  • Cisplatin for lung cancer
  • Thiotepa for breast cancer 1, 2

Recurrence Prevention

• Pericardial window alone may have high recurrence rates (40-70%)
• Consider combined approaches:
  • Extended drainage
  • Intrapericardial therapy
  • Systemic antineoplastic treatment 1, 2

Outcomes and Complications

Efficacy

• Effective in preventing recurrent effusions in most cases
• Less definitive than pericardiectomy
• Recurrent effusions, especially loculated, may require additional interventions 1

Complications

• Wound infection
• Pneumothorax
• Myocardial laceration (rare)
• Mortality (rare in experienced centers) 1, 3

Post-Procedure Management

• Monitor for recurrence of effusion with echocardiography
• Consider systemic therapy for underlying cause (especially in malignancy)
• In cases of neoplastic disease, coordinate care with oncologist for optimal management 1

Contraindications

• Aortic dissection with hemopericardium (absolute)
• Uncorrected coagulopathy
• Anticoagulant therapy
• Thrombocytopenia <50,000/mm³ 2

A pericardial window remains an important palliative procedure for managing recurrent pericardial effusions, particularly in patients with malignant disease where more invasive approaches may not be appropriate due to patient condition or limited life expectancy.